Transcription

1 SPECIAL INVESTIGATIONS UNIT CASES ofinterest

2 Miami Dade / Water Pipe Break: The insured reported that a water supply line under the kitchen sink failed, resulting in water damage throughout the house. The field adjuster noted no evidence of physical damage to the property. Citizens received an Assignment of Benefits and an invoice for $3, from the water mitigation service provider. The SIU investigation discovered that the invoice presented by the water mitigation company was a duplicate of another invoice presented to Citizens for an unrelated claim. SIU interviewed the owner of the water mitigation company who denied that the charges on the mitigation invoice were duplicated from another Citizens claim. The claim, reserved at $14,500, was subsequently denied as there was no physical damage to support that a loss occurred. SIU submitted a referral lt to DIF. Miami Dade/Water Pipe Break: The claim involved an alleged pipe breakage resulting in water damage to the kitchen and bathroom. The field adjuster confirmed with the insured that the plumber referred him to the water mitigation company. Citizens received an Assignment of Benefits and an invoice for $1, from the water mitigation service provider. Citizens retained an expert that stated the cause of loss was attributed to six different points of origin which were unrelated to the reported loss. The insured did not respond to SIU s requests to obtain a recorded interview. SIU interviewed the owner of the water mitigation company who did not recall who referred him to this insured. The claim, reserved at $14,500, was subsequently denied due to prolonged and repeated moisture from multiple sources A DIF referral was submitted. Miami Dade / Water Pipe Break: The insured s attorney reported an alleged pipe break to the supply line causing water damage to the kitchen cabinets. The insured and the attorney had previously filed a similar claim a few months earlier which had been denied for repeated seepage and long term leakage. The SIU investigation developed evidence suggesting that the insured attempted to claim the unrepaired damage in the present claim. After several requests to obtain the insured s interview, the insured s attorney formally withdrew the claim on behalf of the insured. The claim, reserved at $10,500.00, was closed without any further payment. A DIF referral was submitted. Miami Dade / Water Pipe Break: : The insured reported that a water supply line burst causing damage to the kitchen cabinets and flooring. The same public adjuster represented the policyholder for three water loss claims, all involving a plumbing failure in the kitchen. Contrary to the insured s statement, t t SIU investigation revealed dth the damage from the previous losses had never been repaired. The insured failed to show for three scheduled EUOs. The claim, reserved at $33,500 was closed as a result of the insured failing to comply with post loss conditions. SIU submitted a referral to DIF.

3 Miami Dade / Water Pipe Break The Insured reported water damage to the interior of the property and wood floors resulting from a broken supply line in the master bathroom. SIU obtained evidence that the insureds had submitted three prior claims for identical damage to Citizens and the prior carrier. Despite several attempts, the insured failed to provide an interview to SIU. The claim, reserved at $11,225.00, was closed without payment after a formal request to withdrawal the claim was received from the insured. A DIF referral was submitted. Miami Dade / Water Pipe Break: The insured reported water damage to the interior of the property resulting from a broken supply line in the master bathroom. The insured had several previous losses, including a previous denied claim for the same damages reported to Citizens. The claim was voluntarily withdrawn after SIU attempted to obtain the insured s interview, The claim, reserved at $5,000, was closed without any payment after a formal request was received by the insured to withdraw the claim. Miami Dade / Roof Leak: The insured reported a roof leak in the laundry area causing water damage to the ceiling and wall of her residence. The invoice received from the water restoration company reflected a date of loss prior to the loss date reported by the insured. The statement of the Insured revealed that some of the services billed for by the water restoration company were not rendered. An expert confirmed the SIU findings and reported that the damage claimed was a result of a long term leak. The claim, reserved at $12,626.00, was denied as the loss was attributable to long term leakage and seepage. A DIF referral was submitted db based upon the billing misrepresentations i of the water mitigation company. Miami Dade / Water Roof Leak: The insured alleged that a roof leak caused water related damage to the interior of the residence. The insured retained a water mitigation provider to conduct dry out of the residence and signed an Assignment of Benefits. An expert confirmedthatthe the damage was long term termleakageattributableto attributable to anongoing lack of maintenance. The water mitigation service provider filed suit against Citizens based on Breach of Contract under the authority of the Assignment of Benefits. Evidence was developed which suggested the loss was not sudden and accidental. Furthermore, based upon insured s misrepresentations surrounding the circumstances of the loss, Citizens received a Notice of Voluntary Dismissal with Prejudice filed by the water mitigation provider. The claim, reserved at $17,500, was closed without payment. SIU submitted a referral to DIF.

4 Miami Dade / Roof Leak: Insured reported a roof leak causing damage to the ceiling. SIU obtained evidence from the prior carrier s claim file confirming similar damage to the current claim. The insured testified that the roof had been previously replaced, however failed to present receipts in support of the replacement. SIU was unable to find permits recorded for the alleged roof replacement. The claim, reserved at $7,500, was denied as the damage was identical to the previous claim. A DIF referral was submitted. Miami Dade / Roof Leak: The insured reported water damage to the interior of the property as a result of Tropical Storm Isaac. SIU obtained evidence that the insured had filed dth three prior roof losses with ithciti Citizens and a prior carrier. Investigation revealed dth that t although Citizens had paid for a full roof replacement in 2008, under a policy obtained by the insureds husband, the roof appeared old, deteriorated and had never been replaced. Investigation also revealed that the same contractor estimate was used with both carriers in support of the alleged repairs. During their interview with SIU, the insured denied prior damage to the property. The insured appeared for their scheduled EUO, which was curtailed when the insured refused to answer questions and walked out. The insured failed to appear at two subsequent EUOs. The claim, reserved at $5,000 was denied for the insured s failure to cooperate with post loss conditions and failure to appear at the EUO. A DIF referral was submitted. Miami Dade / TS Wind Loss: The insured reported roof and ceiling damage as the result of high winds from Tropical Storm Isaac. During the field adjuster s inspection, evidence of long term leakage/seepage was noted. SIU obtained a recorded interview from the insured revealing that the property was recently purchased as a foreclosure. Citizens retained an expert that confirmed that the roof did not sustain wind damage. The insureds failed to appear at scheduled EUOs and the insureds attorney withdrew the claim. The claim, reserved at $10,000, was closed without payment. SIU submitted a referral to DIF. Miami Dade / Burglary, Theft, VMM: The insured reported burglary to their residence which resulted in theft of personal property and damage to the tile floor, which was continuous throughout the house. The SIU investigation revealed that the insured received an insurance settlement for tile damage in 2011 resulting from a dropped object. Contrary to their statement to SIU, photos obtained from the previous claim depicted that the insured had never replaced the tile floor. Furthermore, SIU was able to identify the same tile damage claimed in the current loss was identical to the previously claimed damage. The claim, reserved at $15,000, was closed without payments after the public adjuster withdrew the claim. A DIF referral was submitted.

5 Monroe County / Burglary, Theft, VMM: The insured reported theft of personal property and vandalism damage resulting from a prior tenant that occupied the rental property. An initial payment of $6, was tendered to the insured for the theft of personal property. The SIU investigation revealed that the insured had reported the loss to police in two separate and unrelated incidents occurring 4 months apart. During his interview with SIU, the insured admitted that he provided conflicting information to Citizens regarding the date of loss. The remaining claim, reserved at $15,000 was denied based upon material misrepresentations in the presentation of the claim. A DIF referral was submitted. Miami Dade i Dd / Dropped dobj Object: : The insured reported tdd damage to a single tile in the kitchen as a result of dropping an unknown object. Citizens scoped the loss and opted to make repairs to the damaged tile. The public adjuster alleged that the repair was not successful and submitted an Appraisal demand for the cost of continuous tile totaling $88,143. A re inspection found the tile repair appeared to have been chemically damaged and that the insured had between 50 to 100 spare floor tiles hidden in the garage. SIU confirmed that the public adjuster and insured were aware of the extra tile and still submitted to appraisal. The insured hired an attorney and filed suit for Breach of Contract. After the attorney was informed of the intentional damage and concealment of the spare floor tiles, the insureds attorney accepted a $1,000 settlement and the case was dismissed. No further payments were made on the claim, which was reserved at $20,000. SIU submitted a referral to DIF. Palm Beach / Water Roof Leak: : The insured reported roof and ceiling damage due to wind and rain associated with Tropical Storm Isaac. During the inspection, evidence of long term leakage was noted. The SIU investigation revealed that Citizens had previously paid a prior claim to the previous owner in 2005 for identical damage that was unrepaired. Further investigation found that a quit claim deed was completed in 2004 giving the current insured all insurable interest in the home while the previous insured maintained the mortgage. The claim, reserved at $24,000, was closed without payment due to pre existing existing damage. SIU submitted a referral to DIF. Volusia / Wind Damage: : The insured reported wind damage from Hurricane Sandy which was reported one month after obtaining a renters policy with Citizens. The insured submitted $7, in receipts for cleaning cost and damaged property in support of their claim. The SIU investigation revealed dth the insured dh had reported a leak in the apartment tt to the landlord prior to obtaining the policy of insurance and which was obtained after the reported roof leak. The claim, reserved at $2,500, was denied. SIU submitted a referral to DIF.

6 St. Petersburg / Wind Loss: A claim for storm related damage to a roof was set up after Citizens received an Assignment of Benefits (AOB), which had been executed by the roofing contractor in support of the claim. The SIU investigation revealed that a receptionist at the property management company overseeing the insured s s rental property signed the AOB with a roofing contractor regarding a wind loss to the insured s property. The receptionist admitted to signing the AOB but subsequently refused to cooperate with SIU s investigation. The claim, reserved at $10, was denied. A DIF referral was submitted. Palm Beach / Water Loss: : The insured reported that upon returning from being out of the country he found water throughout the residence. Citizens found no evidence of water related physical damage to the structure or contents. The insured was unable to provide documentation to corroborate they were out of the country at the time of the loss. A generic repair invoice from Handyman Services could not be validated. An engineer was retained to inspect the property to try and ascertain the cause of loss and extent of the damage. The inspection found no evidence to support the claim. The claim, reserved at $16,000, was denied due to the lack of damage to support the claimed loss. SIU submitted a referral to DIF. Broward / Water Pipe Break: The insured reported water damage claims to Citizens as a result of water leaking from the air conditioning system. The insured stated that the technician repaired the kitchen plumbing and the HVAC system and presented an AC repair invoice. i The repairman was interviewed i and advised di dh that he never worked at the property and the invoice was a fake. The claim, reserved at $10,000, was denied based on the insured intentionally providing a fraudulent invoice for services never rendered. SIU submitted a referral to DIF. Tampa / Sinkhole: The insured reported structural and cosmetic property damage as a result of sinkhole activity, which was filed within the first 6 days of policy inception. During the EUO, the insured testified that the claim was reported after the City of Tampa was repairing a large sinkhole in front of the property. The SIU investigation revealed no evidence indicating any sinkhole repairs to the roadway near the subject property during the alleged time as reported by the insured. The claim, reserved at $72,932, was denied as the damage pre existed existed policy inception. A DIF referral was submitted

7 Tampa / Dropped Object: The insured reported damage to her residence when the ceiling suddenly collapsed, damaging the tile floor. The insured also advised Citizens that he had a new roof installed recently and the damage was not due to water. At the time of inspection the insured had already repaired the ceiling. The SIU Investigation revealed that the insured filed a claim with their previous carrier in 2010 for damage in the master bedroom. It was reported that the ceiling in the master bedroom was cracking and the roof failing. The previous claim file documented water staining to the master bedroom ceiling, slight cracking and it was noted that sections of the roof were in very poor condition. During the EUO, the insured stated that she recalled a claim in 2010 but that it was for other damage and may have extended df from a prior sinkhole claim. li The claim, li reserved at $7,000, was denied as a result of the material misstatement during the EUO. SIU submitted a referral to DIF. Pasco County / Theft, Vandalism: The insured reported a burglary to their residence that resulted in theft of personal property and damage. An initial payment of $12,458 was tendered to the insured. The insured also claimed $23,000 in damage to the tile floor, which was continuous throughout the home. It was discovered that the insured had received a settlement for a previous vandalism loss that included damage to the tile floor. The insured submitted an invoice for more than 3000 sq ft of tile as evidence that the tile had been replaced. An SIU investigation determined that the invoice submitted was an estimate the insured altered to appear as an invoice and the tile was never purchased and the tile had never been replaced. The claim was denied. SIU submitted a referral to DIF. Pinellas / Water Roof Leak (Major Case Update): The insured reported that their property sustained roof damage resulting from a wind event. The roof claim was submitted via a roofing company after the company sought out the insured. The insured entered into a contract with the roofing company to perform any and all necessary repairs. The contract specifically stated that if the claim was paid by the insurance company and the insured did not allow the contractor to complete the work, the insured would be responsible for 20 percent of the value of the repairs. The contract added that if no payment was made by the insurer, nothing would be owed by the insured. It was determined that after the claim was denied by Citizens, the contractor exerted pressure on the insured to file for mediation or be responsible for 20 percent of the value of the contract. SIU submitted a referral to DIF.